Provider Demographics
NPI:1497780563
Name:HABERMAN, MARK D (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:D
Last Name:HABERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 CRAVEN RD STE 201
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-4237
Mailing Address - Country:US
Mailing Address - Phone:760-291-6650
Mailing Address - Fax:760-737-3430
Practice Address - Street 1:225 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4212
Practice Address - Country:US
Practice Address - Phone:760-291-6700
Practice Address - Fax:760-737-3430
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG83540208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110231975OtherMEDICARE RR
CA00G835400OtherBLUE SHIELD
CA00G835400OtherBLUE SHIELD
CA110231975OtherMEDICARE RR